Diagnose Root Causes

Root Cause Analysis

A Root Cause Analysis (RCA) is often used in quality improvement efforts to understand why undesirable incidents occur. RCAs identify the fundamental or deepest reasons for unwanted conditions or outcomes and use those findings to make changes to minimize reoccurrence. RCAs are typically used in healthcare to identify general opportunities to improve quality of care and outcomes. Different tools such as process-mapping, the “5-Whys,”and a Cause-and- Effect Diagram (e.g., the Fishbone Diagram) are used to conduct an RCA. They provide a framework that helps teams identify and organize a problem’s potential causes and specific drivers.

Root Cause Analysis with an Equity Lens

RCAs can be used to identify opportunities to reduce and eliminate health and healthcare inequities by applying what AHE calls an “equity lens”. An equity lens is a filter that helps identify the issues that contribute to the difference in quality of care and outcomes.

Let’s take as an example children with asthma. Say a healthcare organization recognizes that there are healthcare disparities among the children they serve with asthma. Black children seem to be the most significantly affected, particularly in terms of needing inpatient treatment. While conducting their RCA without an equity lens would certainly raise important opportunities to improve the quality of asthma care for all children, it would not necessarily address the inequities specifically experienced by the organization’s Black children with asthma.

For example, the organization might ask, “What is keeping us from being successful at keeping Black children with asthma out of the hospital?” In answering the question, one of the team members might note that care teams at the health system lack adequate time to teach children and their families about asthma management. Giving care teams more time for asthma education is important to address. However, because it likely affects all patients, it does not explain the difference in the organization’s ability to help Black children stay out of the hospital compared to other children.

Inequities happen for many reasons, but they are often related to lapses in communication, cultural biases, and discrimination such as racism, heterosexism, classism, ageism, etc. To get at the root of why an inequity occurs, consider engaging your inner five-year-old by repeatedly asking one simple question: Why?

Why ask “Why?”

Conducting an Equity-Focused RCA

An RCA isn’t one singular action, but rather a set of actions. When conducted properly, an RCA requires investing time and resources to gather information and perspectives from multiple types of key stakeholders. The “Diagnosing Root Causes With an Equity Lens” Resource document provides critical information to guide you through the RCA process. You might also reference “Conducting A Root Cause Analysis with an Equity Lens: Key Considerations” which outlines various topics and ideas to consider for different levels of the healthcare system as you apply an equity lens to your RCA.

Creating a Fishbone Diagram: Points of Consideration

A fishbone diagram provides a framework that helps teams identify and organize the potential causes of a specific health or healthcare inequity in a single chart. It also makes it easier to visualize and share the findings. Below, find issues to consider as your team begins completing its fishbone diagram:

The issues most relevant to the priority population.

Using the example from the 5 Whys exercise, one might conclude that it is important to partner with Black children with asthma and their families. The children and their families will have critical information those within the health system may not be aware of about why the inequity is occurring and how it can be addressed. See the Roadmap’s Essential Elements for more information about partnering with patients and communities.

Actions (or inaction) taken by the healthcare team as it relates to care of the priority population.

Asking the right questions when a health system, health plan, or governmental organization uses an equity lens in conjunction with their RCA will yield better results. The main question of an equity-focused RCA should center on the role the health system plays. For example, “Why are we less successful keeping our Black children with asthma out of the hospital compared to other children with asthma?” focuses on the health system’s actions (e.g., care providers, payers, regulatory and policy factors) rather than the patients and their families. Centering on the health system will reveal what the system can change to have the largest positive impact on the patient populations.

The role that social drivers of health (SDOH) might play in creating or maintaining the inequity.

The team should set aside ample time to complete the fishbone diagram. Plan in advance for when and how you will work with key stakeholders to complete it. The Diagnosing Root Causes With an Equity Lens” Resource document (linked above) provides additional information to help you plan.

Creating a Fishbone Diagram: Steps to Completion

Although the steps to complete a fishbone diagram are easy to follow, the process of determining how to fill out the diagram is complex. It requires focused attention as well as input from multiple stakeholders to increase the chances of your team being able to articulate gaps in care that may negatively impact your patient population.

The image below is an example of a free-form fishbone diagram. Note that the example includes some general quality improvement causes that affect all pediatric patients and their families (e.g., providers lack adequate time) and some that could be an underlying cause of the inequity (e.g., power plants are more likely to be located in predominantly Black and Brown neighborhoods).

Steps to Completion

1. Enter the inequity that you are trying to address in the form of a question, at the “head” of the diagram.
2. Enter high-level causes in the blue boxes.
3. Write “Why?” questions under each blue box to arrive at the lowest, fundamental root causes.
4. Expand your fishbone diagram when needed by adding new high-level blue boxes and detail boxes underneath them.

Some teams prefer to use a system-level focus fishbone diagram with the high-level blue boxes pre-populated with categories of analysis.

Don’t forget to revisit the fishbone diagram as your work progresses. There may be new developments or learnings that will lead your team to want to review and amend the diagram as you gather more information designing and implementing your care and payment transformation approaches. Click here for a blank fishbone diagram with step-by-step instructions.